RS 24 3 Library membership application form and reading ...



Library membership application form - Free to joinMy registration detailsI am a Vision Australia client? YES ? NOTitle?Mr ?Mrs ?Ms ?Miss ?Other First name SurnameProperty name (if applicable) e.g. nursing homeStreet addressSuburbStatePostcode Telephone number ( ) Mobile/daytime phone Email addressDate of birth (dd/mm/yyyy) / / My alternate contact In case we have difficulty contacting you, please provide the details of an alternate contact, who doesn’t live with you. Full nameTelephone number ( ) Email addressThis is why I qualify for membershipI have a vision impairment?I have Dyslexia?I have a visual processing disorder?I have another perceptual disability. Please specify: I am unable to hold print books?How I would like to access content My preferred way to read is? Audio ? Braille ? BothEnglish is not my first language. I would like reading materials in this language: Wifi DAISY playerI would like to rent a wifi DAISY player because I have wifi at home. I will complete the DAISY rental form. ? YES ? NO3G DAISY player I would like to rent a 3G DAISY player because I don’t have wifi at home. I will complete the DAISY rental form ? YES ? NOOwn player I have my own player (smart phone, tablet, ipad, computer etc) and will access the online catalogue this way.? YES ? NOLibrary send me materialsI will complete the enclosed Reading Categories form and the Library will choose materials for me? YES ? NOSelect own materialsI want to select my own reading materials online or over the phone, once I am a member.? YES ? NOThis is my preferred 4-8 character password to access the online catalogueMy referrer detailsTo access this service you need a referral. We may contact your referee to certify that you are a person with a print disability.A referrer may be a: diversional therapist, doctor, general practitioner, neurologist, nurse, nursing home staff, occupational therapist, ophthalmologist, optometrist, orientation and mobility instructor, orthoptist, physiotherapist, psychologist, public library staff, social worker, special education teacher, speech pathologist, Vision Australia staff member or welfare officer.TitleFull nameOccupationOrganisationTelephone number ( ) Email addressDepartment of Veteran Affairs recipients onlyIf you are referring a DVA recipient please complete the above and below sections. DVA recipients can only be referred by a: local medical officer (GP), low vision clinic, specialist, optometrist or occupational therapist. DVA Gold Card numberReferrer provider no.Referrer signatureDateOr my alternate referral - travel card or BCA ID cardIf you don’t have a referee, we will accept an official travel card as proof of eligibility. Or a Blind Citizens Australia (BCA) ID card up until 31 Dec 17. Travel card no/BCA ID State and expiry date Other information Please provide any other information that may help us serve you better.Privacy policyView our privacy policy online to see how we use your information: privacy-terms-and-conditions/privacyMember Charter and Terms & ConditionsView online the Member Charter and Terms & Conditions:living-with-low-vision/library/join-the-libraryMy consent I declare that all the information provided in this application is correct. I understand and agree to all the Terms and Conditions enclosed.SignatureDateConsent of my parent/guardian (if applicable)If you are under 16 years old your parent/legal guardian must complete the below details and sign the consent for you.Full name of parent /legal guardianRelationship to applicantTelephone number( )DateReturn this application form toVision Australia Information Library ServicePO Box 1047, HAWTHORN VIC 3122Telephone: 1800 005 965Fax: (03) 9864 9677Email: librarymembership@Reading categories form To have your reading materials automatically sent to you, please select your preferred reading categories. Call us if you need an explanation.Please don’t send me? Sexual content ? Coarse language ? Violent contentAction, Mystery, Crime, War (select all) ?? Adventure Non-Fiction? Adventure Fiction? Crime Fiction? Crime Non-Fiction? Detective and Mystery Fiction? Legal Fiction? Maritime Non-Fiction? Medical Fiction? Political Fiction? Sea Stories? Spy Fiction? Suspense Fiction? War Fiction? War Non-Fiction? WesternsAustralia (select all) ?? Australian Fiction? Australian History? Australia Non-Fiction? Indigenous Fiction? Indigenous Non-Fiction? Outback Australia? Poetry, Australian? Politics, AustralianAutobiography, Biographies (select all) ?? Autobiography? Biographical Fiction? Biography? Biography - Arts? Biography - Australian? Biography - Blind? Biography - Disabled? Biography - Medical? Biography - Military? Biography - Music and Musicians? Biography - Politicians and Statesmen? Biography - Religion? Biography - Royalty? Biography - Science? Biography - Sports? Biography - Stage and Screen ? Biography - WritersCountryside, Animals, Sport, Humour (select all) ?? Animal Stories? Country Life Fiction? Country Life Non-Fiction? Sport and Recreation Activities? Sport and Recreation Fiction? Wit and Humour Fiction? Wit and Humour Non-FictionFamilies, Romance Fiction (select all) ?? Family Chronicles? Family Stories? Glamour Fiction? Historical Romance Fiction? Hospital Stories? Light Romance Fiction? Perceptive Fiction? Romance and Mystery Stories? Romance FictionFantasy, Horror, Sci-Fi, Supernatural (select all) ?? Fantasy? Horror? Science Fiction? Supernatural FictionHistory, Distant Lands (select all) ?? American Fiction? American History? Ancient History? Ancient Historical Fiction ? Asian History? European History? Great Britain Fiction? History ? Historical Fiction? Language Instruction? Myths and Legends? Travel and CultureLiterature, Arts, Alternative Perspectives (select all) ?? 20th Century Literature? 21st Century Literature? Classic Fiction? Drama? Esoteric Literature? Modern Women's Fiction? Music? Performing Arts? Philosophical Fiction? Poetry? Satire? Short StoriesMind & Body, Home & Work(select all) ?? Cookery? Computers and the Internet ? Craft and Hobbies? Finance and Business Management? Gardening? Health Care? Home Management and Pet Care? Inspirational Stories? Men’s Health? Paediatrics and Parenting? Science and Technology? Women’s HealthReligious ? Religious Fiction? Religious LiteraturePersonal, Social, Philosophical Perspectives (select all) ?? Environment? Erotica? Essays? Feminist Fiction? Feminist Non-Fiction? Gay Fiction? Gay Non-Fiction? Language and Cultural Criticism? Lesbian Fiction? Lesbian Non-Fiction? Philosophy? Politics? Psychology? Psychological Fiction? Sociology? Vision ImpairmentMagazine subscriptions (not braille) (select all) ?? Australian Geographic? Australian Women’s weekly? Choice? National Geographic? National Geographic NZ? New Idea? Reader’s Digest ? Silicon Chip? The Monthly? Time Australia? Travel? WheelsNewspaper subscriptions (not braille)When you are a member login to view the full list of newspapers:i-accessonline. Fixtures (braille available)? AFL? NRL? CricketVision Australia updates(not braille)? In Vision? Your Vision Australia RoundupGovernment information? Local council newsletter? Other? Please specify________________________End of Reading Categories Form ................
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